- Disease stages in patients with valvular heart disease should be classified (Stages A, B, C, and D) on the basis of symptoms, valve anatomy, the severity of valve dysfunction, and the response of the ventricle and pulmonary circulation.
- In the evaluation of a patient with valvular heart disease, history and physical examination findings should be correlated with the results of noninvasive testing (i.e., ECG, chest x-ray, transthoracic echocardiogram). If there is discordance between the physical examination and initial noninvasive testing, consider further noninvasive (computed tomography, cardiac magnetic resonance imaging, stress testing) or invasive (transesophageal echocardiography, cardiac catheterization) testing to determine optimal treatment strategy.
- For patients with valvular heart disease and atrial fibrillation (except for patients with rheumatic mitral stenosis or a mechanical prosthesis), the decision to use oral anticoagulation to prevent thromboembolic events, with either a vitamin K antagonist or a non–vitamin K antagonist anticoagulant, should be made in a shared decision-making process based on the CHA2DS2-VASc score. Patients with rheumatic mitral stenosis or a mechanical prosthesis and atrial fibrillation should receive oral anticoagulation with a vitamin K antagonist.
- All patients with severe valvular heart disease being considered for valve intervention should be evaluated by a multidisciplinary team, with either referral to or consultation with a Primary or Comprehensive Valve Center.
- Treatment of severe aortic stenosis with either a transcatheter or surgical valve prosthesis should be based primarily on symptoms or reduced ventricular systolic function. Earlier intervention may be considered if indicated by results of exercise testing, biomarkers, rapid progression, or the presence of very severe stenosis.
- Indications for transcatheter aortic valve implantation are expanding as a result of multiple randomized trials of transcatheter aortic valve implantation atrioversus surgical aortic valve replacement. The choice of type of intervention for a patient with severe aortic stenosis should be a shared decision-making process that considers the lifetime risks and benefits associated with type of valve (mechanical versus bioprosthetic) and type of approach (transcatheter versus surgical).
- Indications for intervention for valvular regurgitation are relief of symptoms and prevention of the irreversible long-term consequences of left ventricular volume overload. Thresholds for intervention now are lower than they were previously because of more durable treatment options and lower procedural risks.
- A mitral transcatheter edge-to-edge repair is of benefit to patients with severely symptomatic primary mitral regurgitation who are at high or prohibitive risk for surgery, as well as to a select subset of patients with secondary mitral regurgitation who remain severely symptomatic despite guideline-directed management and therapy for heart failure.
- Patients presenting with severe symptomatic isolated tricuspid regurgitation, commonly associated with device leads and atrial fibrillation, may benefit from surgical intervention to reduce symptoms and recurrent hospitalizations if done before the onset of severe right ventricular dysfunction or end-organ damage to the liver and kidney.
- Bioprosthetic valve dysfunction may occur because of either degeneration of the valve leaflets or valve thrombosis. Catheter-based treatment for prosthetic valve dysfunction is reasonable in selected patients for bioprosthetic leaflet degeneration or paravalvular leak in the absence of active infection.
Table 1. Evaluation of Patients With Known or Suspected VHD
|Initial evaluation: All patients with known or suspected valve disease||TTE*||Establishes chamber size and function, valve morphology and severity, and effect on pulmonary and systemic circulation|
|History and physical||Establishes symptom severity, comorbidities, valve disease presence and severity, and presence of HF|
|ECG||Establishes rhythm, LV function, and presence or absence of hypertrophy|
|Further diagnostic testing: Information required for equivocal symptom status, discrepancy between examination and echocardiogram, further definition of valve disease, or assessing response of the ventricles and pulmonary circulation to load and to exercise||Chest x-ray||Important for the symptomatic patient; establishes heart size and presence or absence of pulmonary vascular congestion, intrinsic lung disease, and calcification of aorta and pericardium|
|TEE||Provides high-quality assessment of mitral and prosthetic valve, including definition of intracardiac masses and possible associated abnormalities (e.g., intracardiac abscess, LA thrombus)|
|CMR||Provides assessment of LV volumes and function, valve severity, and aortic disease|
|PET CT||Aids in determination of active infection or inflammation|
|Stress testing||Gives an objective measure of exercise capacity|
|Catheterization||Provides measurement of intracardiac and pulmonary pressures, valve severity, and hemodynamic response to exercise and drugs|
|Further risk stratification: Information on future risk of the valve disease, which is important for determination of timing of intervention||Biomarkers||Provide indirect assessment of filling pressures and myocardial damage|
|TTE strain||Helps assess intrinsic myocardial performance|
|CMR||Assesses fibrosis by gadolinium enhancement|
|Stress testing||Provides prognostic markers|
|Procedural risk||Quantified by STS (Predicted Risk of Mortality) and TAVI scores|
|Frailty score||Provides assessment of risk of procedure and chance of recovery of quality of life|
|Preprocedural testing: Testing required before valve intervention||Dental examination||Rules out potential infection sources|
|CT coronary angiogram or invasive coronary angiogram||Gives an assessment of coronary anatomy|
|CT: peripheral||Assesses femoral access for TAVI and other transcatheter procedures|
|CT: cardiac||Assesses suitability for TAVI and other transcatheter procedures|
Table 2. Stages of Progression of VHD
|A||At risk||Patients with risk factors for development of VHD|
|B||Progressive||Patients with progressive VHD (mild-to-moderate severity and asymptomatic)|
|C||Asymptomatic severe||Asymptomatic patients who meet the criteria for severe VHD:|
C1: Asymptomatic patients with severe VHD in whom the left or right ventricle remains compensated
C2: Asymptomatic patients with severe VHD, with decompensation of the left or right ventricle
|D||Symptomatic severe||Patients who have developed symptoms as a result of VHD|
Table 3. Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal Left Ventricular (LV) Function
|Every 3–5 y (mild severity; Vmax 2.0–2.9 m/s)||Every 3–5 y (mild severity)||Every 3–5 y (mitral valve area [MVA] >1.5 cm2)||Every 3–5 y (mild severity)|
|Every 1–2 y (moderate severity; Vmax 3.0–3.9 m/s)||Every 1–2 y (moderate severity)||Every 1–2 y (moderate severity)|
|Every 6–12 mo (Vmax ≥4 m/s)||Every 6–12 mo||Every 1–2 y (MVA 1.0–1.5 cm2)||Every 6–12 mo|
|Dilating LV: more frequently||Every year (MVA <1.0 cm2)||Dilating LV: more frequently|
* With normal stroke volume.
Table 4. Secondary Prevention of Rheumatic Fever
|Antibiotics for Prevention||Dosage*|
|Penicillin G benzathine||1.2 million U intramuscularly every 4 wk†|
|Penicillin V potassium||200 mg orally twice daily|
|Sulfadiazine||1 g orally once daily|
|Macrolide or azalide antibiotic (for patients allergic to penicillin and sulfadiazine)‡||Varies|
† Administration every 3 wk is recommended in certain high-risk situations.
‡ Macrolide antibiotics should not be used in persons taking other medications that inhibit cytochrome P450 3A, such as azole antifungal agents, HIV protease inhibitors, and some selective serotonin reuptake inhibitors.
Table 5. Duration of Secondary Prophylaxis for Rheumatic Fever
|Type||Duration After Last Attack*|
|Rheumatic fever with carditis and residual heart disease (persistent VHD†)||10 y or until patient is 40 y of age (whichever is longer)|
|Rheumatic fever with carditis but no residual heart disease (no valvular disease†)||10 y or until patient is 21 y of age (whichever is longer)|
|Rheumatic fever without carditis||5 y or until patient is 21 y of age (whichever is longer)|
† Clinical or echocardiographic evidence.
2.4.1. Secondary Prevention of Rheumatic Fever
|1||C-EO||In patients with rheumatic heart disease, secondary prevention of rheumatic fever is indicated (Tables 4 and 5).|
2.4.2. IE Prophylaxis
|2a||C-LD||Antibiotic prophylaxis is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with VHD who have any of the following:|
|3: No Benefit||B-NR||In patients with VHD who are at high risk of IE, antibiotic prophylaxis is not recommended for nondental procedures (e.g., TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection.|
2.4.3. Anticoagulation for AF in Patients With VHD
|1||A||For patients with AF and native valve heart disease (except rheumatic mitral stenosis [MS]) or who received a bioprosthetic valve >3 months ago, a non–vitamin K oral anticoagulant (NOAC) is an effective alternative to VKA anticoagulation and should be administered on the basis of the patient’s CHA2DS2-VASc score.|
|1||C-EO||For patients with AF and rheumatic MS, long-term VKA oral anticoagulation is recommended.|
|2a||B-NR||For patients with new-onset AF ≤3 months after surgical or transcatheter bioprosthetic valve replacement, anticoagulation with a VKA is reasonable.|
|3: Harm||B-R||In patients with mechanical heart valves with or without AF who require long-term anticoagulation with VKA to prevent valve thrombosis, NOACs are not recommended.|
Figure 1. Anticoagulation for AF in Patients With VHDColors correspond to the Class of Recommendation
2.5. Evaluation of Surgical and Interventional Risk
|1||C-EO||For patients with VHD for whom intervention is contemplated, individual risks should be calculated for specific surgical and/or transcatheter procedures, using online tools when available, and discussed before the procedure as a part of a shared decision-making process.|
Table 6. Risk Assessment for Surgical Valve Procedures
(Must Meet ALL Criteria in This Column)
|Low-Risk Surgical Mitral Valve Repair for Primary MR|
(Must Meet ALL Criteria in This Column)
|High Surgical Risk|
(Any 1 Criterion in This Column)
|Prohibitive Surgical Risk|
(Any 1 Criterion in This Column)
|STS-predicted risk of death*||<3%|
|Predicted risk of death or major morbidity (all-cause) >50% at 1 y OR|
|≥2 Indices (moderate to severe)|
|≥2 Indices (moderate to severe)|
|Cardiac or other major organ system compromise not to be improved postoperatively‡||None|
|1 to 2 Organ systems|
|≥3 Organ systems|
|Procedure-specific impediment§||None||None||Possible procedure-specific impediment||Severe procedure-specific impediment|
† Seven frailty indices: Katz Activities of Daily Living (independence in feeding, bathing, dressing, transferring, toileting, and urinary continence) plus independence in ambulation (no walking aid or assistance required, or completion of a 5-m walk in <6 s). Other scoring systems can be applied to calculate no, mild, or moderate to severe frailty.
‡ Examples of major organ system compromise include cardiac dysfunction (severe LV systolic or diastolic dysfunction or RV dysfunction, fixed pulmonary hypertension); kidney dysfunction (chronic kidney disease, stage 3 or worse); pulmonary dysfunction (FEV1 <50% or DLCO2 <50% of predicted); central nervous system dysfunction (dementia, Alzheimer’s disease, Parkinson’s disease, cerebrovascular accident with persistent physical limitation); gastrointestinal dysfunction (Crohn’s disease, ulcerative colitis, nutritional impairment, or serum albumin <3.0); cancer (active malignancy); and liver dysfunction (any history of cirrhosis, variceal bleeding, or elevated INR in the absence of VKA therapy).
§ Examples of procedure-specific impediments include presence of tracheostomy, heavily calcified (porcelain) ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall, and radiation damage.
Table 7. Examples of Procedure-Specific Risk Factors for Interventions Not Incorporated Into Existing Risk Scores
|SAVR||TAVI||Surgical MV Repair or Replacement||Transcatheter Edge-to-Edge Mitral Valve Repair|
|Technical or anatomic|
Table 8. Median Operative Mortality Rates for Specific Surgical Procedures (STS Adult Cardiac Surgery Database, 2019
|Procedure||Mortality Rate (%)|
|AVR and CABG||4|
|AVR and Mitral Valve replacement||9|
|Mitral Valve replacement||5|
|Mitral Valve replacement and CABG||9|
|Mitral Valve repair||1|
|Mitral Valve repair and CABG||5|
2.6. The Multidisciplinary Heart Valve Team and Heart Valve Centers
|1||C-EO||Patients with severe VHD should be evaluated by a Multidisciplinary Heart Valve Team (MDT) when intervention is considered.|
|2a||C-LD||Consultation with or referral to a Primary or Comprehensive Heart Valve Center is reasonable when treatment options are being discussed for 1) asymptomatic patients with severe VHD, 2) patients who may benefit from valve repair versus valve replacement, or 3) patients with multiple comorbidities for whom valve intervention is considered.|
Table 9. Structure of Primary and Comprehensive Valve Centers
|Comprehensive (Level I) Valve Center||Primary (Level II) Valve Center|
|Percutaneous aortic valve balloon dilation||Percutaneous aortic valve balloon dilation|
|TAVI–alternative access, including transthoracic (transaortic, transapical) and extrathoracic (e.g., subclavian, carotid, caval) approaches|
|Mitral transcatheter edge-to-edge repair|
|Prosthetic valve paravalvular leak closure|
|Percutaneous mitral balloon commissurotomy|
|Valve-sparing aortic root procedures|
|Aortic root procedures for aneurysmal disease|
|Concomitant septal myectomy with AVR|
|Root enlargement with AVR|
|Mitral repair for primary MR||Mitral repair for posterior leaflet primary MR†|
|Mitral valve replacement‡||Mitral valve replacement‡|
|Reoperative valve surgery|
|Isolated or concomitant tricuspid valve repair or replacement||Concomitant tricuspid valve repair or replacement with mitral surgery|
|Echocardiographer with expertise in valve disease and transcatheter and surgical interventions||Echocardiographer with expertise in valve disease and transcatheter and surgical interventions|
|Expertise in CT with application to valve assessment and procedural planning||Expertise in CT with application to valve assessment and procedural planning|
|Interventional echocardiographer to provide imaging guidance for transcatheter and intraoperative procedures|
|Expertise in cardiac MRI with application to assessment of VHD|
|Criteria for Imaging Personnel|
|A formalized role/position for a “valve echocardiographer” who performs both the pre- and postprocedural assessment of valve disease||A formalized role/position for a “valve echocardiographer” who performs both the pre- and postprocedural assessment of valve disease|
|A formalized role/position for the expert in CT who oversees the preprocedural assessment of patients with valve disease||A formalized role/position for the expert in CT who oversees the preprocedural assessment of patients with valve disease|
|A formalized role/position for an interventional echocardiographer|
|Institutional Facilities and Infrastructure|
|A formalized role/position for a dedicated valve coordinator who organizes care across the continuum and system of care||A formalized role/position for a dedicated valve coordinator who organizes care across the continuum and system of care|
|Cardiac anesthesia support||Cardiac anesthesia support|
|Palliative care team||Palliative care team|
|Vascular surgery support||Vascular surgery support|
|Neurology stroke team||Neurology stroke team|
|Consultative services with other cardiovascular subspecialties|
|Consultative services with other medical and surgical subspecialties|
|Echocardiography–3D TEE; comprehensive TTE for assessment of valve disease||Echocardiography–comprehensive TTE for assessment of valve disease|
|Cardiac CT||Cardiac CT|
|Temporary mechanical support (including percutaneous support devices such as intra-aortic balloon counterpulsation, temporary percutaneous ventricular assist device or ECMO)||Temporary mechanical support (including percutaneous support devices such as intra-aortic balloon counterpulsation, temporary percutaneous ventricular assist device or ECMO)|
|Left/right ventricular assist device capabilities (on-site or at an affiliated institution)|
|Cardiac catheterization laboratory, hybrid catheterization laboratory, or hybrid OR laboratory§||Cardiac catheterization laboratory|
|PPM and ICD implantation||PPM and ICD implantation|
|Institutional Facilities and Infrastructure|
|IAC echocardiography laboratory accreditation||IAC echocardiography laboratory accreditation|
|24/7 intensivist coverage for ICU|
† If intraoperative imaging and surgical expertise exist.
‡ If mitral valve anatomy is not suitable for valve repair.
§ Equipped with a fixed radiographic imaging system and flat-panel fluoroscopy, offering catheterization laboratory-quality imaging and hemodynamic capability. Used with permission from Nishimura et al. J Am Coll Cardiol. 2019;73:2609-35.
2.7.4. Periodic Imaging After Valve Intervention
|1||C-EO||In asymptomatic patients with any type of valve intervention, a baseline postprocedural TTE followed by periodic monitoring with TTE is recommended, depending on type of intervention, length of time after intervention, ventricular function, and concurrent cardiac conditions.|
Table 10. Timing of Periodic Imaging After Valve Intervention
|Valve Intervention||Minimal Imaging Frequency†||Location|
|Mechanical valve (surgical)||Baseline||Primary Valve Center|
|Bioprosthetic valve (surgical)||Baseline, 5 and 10 y after surgery,‡ and then annually||Primary Valve Center|
|Bioprosthetic valve (transcatheter)||Baseline and then annually||Primary Valve Center|
|Mitral valve repair (surgical)||Baseline, 1 y, and then every 2–3 y||Primary Valve Center|
|Mitral valve repair (transcatheter)||Baseline and then annually||Comprehensive Valve Center|
|Bicuspid aortic valve disease||Continued post-AVR monitoring of aortic size if aortic diameter is ≥4.0 cm at time of AVR, as detailed in Section 5.1||Primary Valve Center|
† Repeat imaging is appropriate at shorter follow-up intervals for changing signs or symptoms, during pregnancy, and to monitor residual or concurrent cardiac dysfunction.
‡ Imaging may be done more frequently in patients with bioprosthetic surgical valves if there are risk factors for early valve degeneration (e.g., younger age, renal failure, diabetes).
Table 11. Stages of AS
|Stage||Definition||Valve Anatomy||Valve Hemodynamics||Hemodynamic Consequences||Symptoms|
|A||At risk of AS||Aortic Vmax <2 m/s with normal leaflet motion||None||None|
|C: Asymptomatic severe AS|
|C1||Asymptomatic severe AS||Severe leaflet calcification or congenital stenosis with severely reduced leaflet opening||None: Exercise testing is reasonable to confirm symptom status|
|C2||Asymptomatic severe AS with LV dysfunction||Severe leaflet calcification/fibrosis or congenital stenosis with severely reduced leaflet opening||LVEF <50%||None|
|D: Symptomatic severe AS|
|D1||Symptomatic severe high- gradient AS||Severe leaflet calcification/fibrosis or congenital stenosis with severely reduced leaflet opening|
|D2||Symptomatic severe low-flow/low-gradient AS with reduced LVEF||Severe leaflet calcification with severely reduced leaflet motion|
|D3||Symptomatic severe low-gradient AS with normal LVEF or paradoxical low-flow severe AS||Severe leaflet calcification/fibrosis with severely reduced leaflet motion|
22.214.171.124. Diagnostic Testing: Initial Diagnosis
|1||A||In patients with signs or symptoms of AS or a BAV, TTE is indicated for accurate diagnosis of the cause of AS, assessment of hemodynamic severity, measurement of LV size and systolic function, and determination of prognosis and timing of valve intervention.|
|1||B-NR||In patients with suspected low-flow, low-gradient severe AS with normal LVEF (Stage D3), optimization of blood pressure control is recommended before measurement of AS severity by TTE, TEE, cardiac catheterization, or CMR.|
|2a||B-NR||In patients with suspected low-flow, low-gradient severe AS with reduced LVEF (Stage D2), low-dose dobutamine stress testing with echocardiographic or invasive hemodynamic measurements is reasonable to further define severity and assess contractile reserve.|
|2a||B-NR||In patients with suspected low-flow, low-gradient severe AS with normal or reduced LVEF (Stages D2 and D3), calculation of the ratio of the outflow tract to aortic velocity is reasonable to further define severity.|
|2a||B-NR||In patients with suspected low-flow, low-gradient severe AS with normal or reduced LVEF (Stages D2 and D3), measurement of aortic valve calcium score by CT imaging is reasonable to further define severity.|
126.96.36.199. Diagnostic Testing: Exercise Testing
|2a||B-NR||In asymptomatic patients with severe AS (Stage C1), exercise testing is reasonable to assess physiological changes with exercise and to confirm the absence of symptoms.|
|3: Harm||B-NR||In symptomatic patients with severe AS (Stage D1, aortic velocity ≥4.0 m/s or mean pressure gradient ≥40 mm Hg), exercise testing should not be performed because of the risk of severe hemodynamic compromise.|
3.2.2. Medical Therapy
|1||B-NR||In patients at risk of developing AS (Stage A) and in patients with asymptomatic AS (Stages B and C), hypertension should be treated according to standard GDMT, started at a low dose, and gradually titrated upward as needed, with appropriate clinical monitoring.|
|1||A||In all patients with calcific AS, statin therapy is indicated for primary and secondary prevention of atherosclerosis on the basis of standard risk scores.|
|2b||B-NR||In patients who have undergone TAVI, renin–angiotensin system blocker therapy (ACE inhibitor or ARB) may be considered to reduce the long-term risk of all-cause mortality.|
|3: No Benefit||A||In patients with calcific AS (Stages B and C), statin therapy is not indicated for prevention of hemodynamic progression of AS.|
3.2.3. Timing of Intervention
|1||A||In adults with severe high-gradient AS (Stage D1) and symptoms of exertional dyspnea, HF, angina, syncope, or presyncope by history or on exercise testing, AVR is indicated.|
|1||B-NR||In asymptomatic patients with severe AS and an LVEF <50% (Stage C2), AVR is indicated.|
|1||B-NR||In asymptomatic patients with severe AS (Stage C1) who are undergoing cardiac surgery for other indications, AVR is indicated.|
|1||B-NR||In symptomatic patients with low-flow, low-gradient severe AS with reduced LVEF (Stage D2), AVR is recommended.|
|1||B-NR||In symptomatic patients with low-flow, low-gradient severe AS with normal LVEF (Stage D3), AVR is recommended if AS is the most likely cause of symptoms.|
|2a||B-NR||In apparently asymptomatic patients with severe AS (Stage C1) and low surgical risk, AVR is reasonable when an exercise test demonstrates decreased exercise tolerance (normalized for age and sex) or a fall in systolic blood pressure of ≥10 mm Hg from baseline to peak exercise.|
|2a||B-R||In asymptomatic patients with very severe AS (defined as an aortic velocity of ≥5 m/s) and low surgical risk, AVR is reasonable.|
|2a||B-NR||In apparently asymptomatic patients with severe AS (Stage C1) and low surgical risk, AVR is reasonable when the serum B-type natriuretic peptide (BNP) level is >3 times normal.|
|2a||B-NR||In asymptomatic patients with high-gradient severe AS (Stage C1) and low surgical risk, AVR is reasonable when serial testing shows an increase in aortic velocity ≥0.3 m/s per year.|
|2b||B-NR||In asymptomatic patients with severe high-gradient AS (Stage C1) and a progressive decrease in LVEF on at least 3 serial imaging studies to <60%, AVR may be considered.|
|2b||C-EO||In patients with moderate AS (Stage B) who are undergoing cardiac surgery for other indications, AVR may be considered.|
Figure 2. Timing of Intervention for ASColors correspond to the Class of Recommendation.
Arrows show the decision pathways that result in a recommendation for AVR. Periodic monitoring is indicated for all patients in whom AVR is not yet indicated, including those with asymptomatic (Stage C) and symptomatic (Stage D) AS and those with low-gradient AS (Stage D2 or D3) who do not meet the criteria for intervention.
See Section 3.2.4 for choice of valve type (mechanical versus bioprosthetic [TAVR or SAVR]) when AVR is indicated.
188.8.131.52. Choice of Mechanical Versus Bioprosthetic AVR
|1||C-EO||In patients with an indication for AVR, the choice of prosthetic valve should be based on a shared decision-making process that accounts for the patient’s values and preferences and includes discussion of the indications for and risks of anticoagulant therapy and the potential need for and risks associated with valve reintervention.|
|1||C-EO||For patients of any age requiring AVR for whom VKA anticoagulant therapy is contraindicated, cannot be managed appropriately, or is not desired, a bioprosthetic AVR is recommended.|
|2a||B-R||For patients <50 years of age who do not have a contraindication to anticoagulation and require AVR, it is reasonable to choose a mechanical aortic prosthesis over a bioprosthetic valve.|
|2a||B-NR||For patients 50 to 65 years of age who require AVR and who do not have a contraindication to anticoagulation, it is reasonable to individualize the choice of either a mechanical or bioprosthetic AVR with consideration of individual patient factors and after informed shared decision-making.|
|2a||B-R||In patients >65 years of age who require AVR, it is reasonable to choose a bioprosthesis over a mechanical valve.|
|2b||B-NR||In patients <50 years of age who prefer a bioprosthetic AVR and have appropriate anatomy, replacement of the aortic valve by a pulmonic autograft (the Ross procedure) may be considered at a Comprehensive Valve Center.|
184.108.40.206. Choice of SAVR Versus TAVI for Patients for Whom a Bioprosthetic AVR Is Appropriate
|1||A||For symptomatic and asymptomatic patients with severe AS and any indication for AVR who are <65 years of age or have a life expectancy >20 years, SAVR is recommended.|
|1||A||For symptomatic patients with severe AS who are 65 to 80 years of age and have no anatomic contraindication to transfemoral TAVI, either SAVR or transfemoral TAVI is recommended after shared decision-making about the balance between expected patient longevity and valve durability.|
|1||A||For symptomatic patients with severe AS who are >80 years of age or for younger patients with a life expectancy <10 years and no anatomic contraindication to transfemoral TAVI, transfemoral TAVI is recommended in preference to SAVR.|
|1||B-NR||In asymptomatic patients with severe AS and an LVEF <50% who are ≤80 years of age and have no anatomic contraindication to transfemoral TAVI, the decision between TAVI and SAVR should follow the same recommendations as for symptomatic patients in Recommendations 1, 2, and 3 above.|
|1||B-NR||For asymptomatic patients with severe AS and an abnormal exercise test, very severe AS, rapid progression, or an elevated BNP (COR 2a indications for AVR), SAVR is recommended in preference to TAVI.|
|1||A||For patients with an indication for AVR for whom a bioprosthetic valve is preferred but valve or vascular anatomy or other factors are not suitable for transfemoral TAVI, SAVR is recommended.|
|1||A||For symptomatic patients of any age with severe AS and a high or prohibitive surgical risk, TAVI is recommended if predicted post-TAVI survival is >12 months with an acceptable quality of life.|
|1||C-EO||For symptomatic patients with severe AS for whom predicted post-TAVI or post-SAVR survival is <12 months or for whom minimal improvement in quality of life is expected, palliative care is recommended after shared decision-making, including discussion of patient preferences and values.|
|2b||C-EO||In critically ill patients with severe AS, percutaneous aortic balloon dilation may be considered as a bridge to SAVR or TAVI.|
Figure 3. Choice of SAVR Versus TAVI When AVR is Indicated for Valvular ASColors correspond to the Class of Recommendation.
* Approximate ages, based on US Actuarial Life Expectancy tables, are provided for guidance. The balance between expected patient longevity and valve durability varies continuously across the age range, with more durable valves preferred for patients with a longer life expectancy. Bioprosthetic valve durability is finite (with shorter durability for younger patients) whereas mechanical valves are very durable but require life-long anticoagulation. Long-term (20 year) data on outcomes with surgical bioprosthetic valves is available; robust data on transcatheter bioprosthetic valves only extends to 5 years leading to uncertainty about longer term outcomes. The decision about valve type should be individualized based on patient specific factors that might affect expected longevity.
† Placement of a transcatheter valve requires vascular anatomy that allows transfemoral delivery and the absence of aortic root dilation that would require surgical replacement. Valvular anatomy must be suitable for placement of the specific prosthetic valve including annulus size and shape, leaflet number and calcification and coronary ostial height. See ACC Expert Consensus Statement.
Table 12. A Simplified Framework With Examples of Factors Favoring SAVR, TAVI, or Palliation Instead of Aortic Valve Intervention
|Favors SAVR||Favors TAVI||Favors Palliation|
|Prosthetic valve preference|
|Concurrent cardiac conditions|
|Estimated procedural or surgical risk of SAVR or TAVI|
|Goals of Care and patient preferences and values|
† A large aortic annulus may not be suitable for currently available transcatheter valve sizes. With a small aortic annulus or aorta, a surgical annulus-enlarging procedure may be needed to allow placement of a larger prosthesis and avoid patient–prosthesis mismatch.
‡ Dilation of the aortic sinuses or ascending aorta may require concurrent surgical replacement, particularly in younger patients with a BAV.
Table 13. Stages of Chronic Aortic Regurgitation (AR)
|Stage||Definition||Valve Anatomy||Valve Hemodynamics||Hemodynamic Consequences||Symptoms|
|A||At risk of AR||AR severity: none or trace||None||None|
|B||Progressive AR||Mild AR:||None|
|C||Asymptomatic severe AR||Severe AR:||C1:||None; exercise testing is reasonable to confirm symptom status|
|D||Symptomatic severe AR||Severe AR:||Exertional dyspnea or angina or more severe HF symptoms|
4.3.1. Diagnosis of Chronic AR
|1||B-NR||In patients with signs or symptoms of AR, TTE is indicated for assessment of the cause and severity of regurgitation, LV size and systolic function, prognosis, and timing of valve intervention.|
|1||B-NR||In patients with a BAV or with known dilation of the aortic sinuses or ascending aorta, TTE is indicated to evaluate the presence and severity of AR.|
|1||B-NR||In patients with moderate or severe AR and suboptimal TTE images or a discrepancy between clinical and TTE findings, TEE, CMR, or cardiac catheterization is indicated for the assessment of LV systolic function, systolic and diastolic volumes, aortic size, and AR severity.|
4.3.2. Medical Therapy
|1||B-NR||In asymptomatic patients with chronic AR (Stages B and C), treatment of hypertension (systolic blood pressure >140 mm Hg) is recommended.|
|1||B-NR||In patients with severe AR who have symptoms and/or LV systolic dysfunction (Stages C2 and D) but a prohibitive surgical risk, GDMT for reduced LVEF with ACE inhibitors, ARBs, and/or sacubitril/valsartan is recommended.|
4.3.3. Timing of Intervention
|1||B-NR||In symptomatic patients with severe AR (Stage D), aortic valve surgery is indicated regardless of LV systolic function.|
|1||B-NR||In asymptomatic patients with chronic severe AR and LV systolic dysfunction (LVEF ≤55%) (Stage C2), aortic valve surgery is indicated if no other cause for systolic dysfunction is identified.|
|1||C-EO||In patients with severe AR (Stage C or D) who are undergoing cardiac surgery for other indications, aortic valve surgery is indicated.|
|2a||B-NR||In asymptomatic patients with severe AR and normal LV systolic function (LVEF >55%), aortic valve surgery is reasonable when the LV is severely enlarged (LVESD >50 mm or indexed LVESD 25 mm/m2) (Stage C2).|
|2a||C-EO||In patients with moderate AR (Stage B) who are undergoing cardiac or aortic surgery for other indications, aortic valve surgery is reasonable.|
|2b||B-NR||In asymptomatic patients with severe AR and normal LV systolic function at rest (LVEF >55%; Stage C1) and low surgical risk, aortic valve surgery may be considered when there is a progressive decline in LVEF on at least 3 serial studies to the low–normal range (LVEF 55% to 60%) or a progressive increase in LV dilation into the severe range (LV end-diastolic dimension [LVEDD] 65 mm).|
|3: Harm||B-NR||In patients with isolated severe AR who have indications for SAVR and are candidates for surgery, TAVI should not be performed.|